Pending Regulatory Approval
Full PPO Split Deductible 10-250 90/70
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning On or After 01/01/2015
Coverage for: Individual + Family | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.blueshieldca.com or by calling 1-800-200-3242.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
For participating providers:
$250 per individual / $500 per
family.
For non-participating providers:
$500 per individual / $1,000 per
family.
Does not apply to emergency room
facility services not resulting in
admission, participating physician
and specialist office visits, breast
pump, preventive health services and
outpatient prescription drug benefits.
You must pay all the costs up to the deductible amount before this plan begins to pay
for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on
page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
No.
You don't have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
Is there an out–of–
pocket limit on my
expenses?
Yes. For participating providers:
$1,750 per individual / $3,500 per
family.
For non-participating providers:
$3,500 per individual / $7,000 per
family.
The out-of-pocket limit is the most you could pay during a coverage period (usually
one year) for your share of the cost of covered services. This limit helps you plan for
health care expenses.
What is not included in
the out–of–pocket
limit?
Premiums, balance-billed charges,
some copayments, and health care
this plan doesn't cover.
Even though you pay these expenses, they don't count toward the out-of-pocket
limit.
Is there an overall
annual limit on what
the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
1 of 16
Pending Regulatory Approval
Important Questions
Answers
Why this Matters:
Does this plan use a
network of providers?
Yes. See www.blueshieldca.com or
call 1-800-200-3242 for a list of
participating providers.
If you use an in-network doctor or other health care provider, this plan will pay some
or all of the costs of covered services. Be aware, your in-network doctor or hospital
may use an out-of-network provider for some services. Plans use the term in-network,
preferred, or participating for providers in their network. See the chart starting on
page 2 for how this plan pays different kinds of providers.
Do I need a referral to
see a specialist?
No.
You can see the specialist you choose without permission from this plan.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn't cover are listed on page 12. See your policy or
plan document for additional information about excluded services.
 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
 The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
 This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
Services You May Need
Primary care visit to treat an
injury or illness
Your Cost If You Use a
Participating Provider
$10 copayment / visit
Your Cost If You Use
a Non-Participating
Provider
30% coinsurance
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Limitations & Exceptions
For other services received during
the office visit, additional member
cost-share may apply.
Not subject to the calendar-year
medical deductible at participating
providers.
Blue Shield of California is an independent
member of the Blue Shield Association.
2 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Specialist visit
Other practitioner office visit
Preventive care/screening
/immunization
Your Cost If You Use a
Participating Provider
Your Cost If You Use
a Non-Participating
Provider
$10 copayment / visit
30% coinsurance
Chiropractic:
$25 copayment / visit
Chiropractic:
50% coinsurance
Acupuncture:
$25 copayment / visit
Acupuncture:
30% coinsurance
No Charge
Not Covered
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Limitations & Exceptions
For other services received during
the office visit, additional member
cost-share may apply.
Not subject to the calendar-year
medical deductible at participating
providers.
Coverage for chiropractic services is
limited to 12 visits per calendar year.
Coverage for acupuncture services is
limited to 20 visits per calendar year.
Additional member cost-share
applies for covered X-ray services
received in conjunction with the
office visit.
Preventive health services are only
covered when provided by
participating providers.
Coverage for services consistent with
ACA requirements and California
laws. Please refer to your plan
contract for details.
Not subject to the calendar-year
medical deductible.
Blue Shield of California is an independent
member of the Blue Shield Association.
3 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Your Cost If You Use a
Participating Provider
Your Cost If You Use
a Non-Participating
Provider
Lab & Path at Free Standing Lab & Path at Free
Location:
Standing Location:
$10 copayment / visit
30% coinsurance
Diagnostic test (x-ray, blood
work)
If you have a test
Imaging (CT/PET scans,
MRIs)
X-Ray & Imaging at Free
Standing Radiology Center:
$10 copayment / visit
X-Ray & Imaging at Free
Standing Radiology Center:
30% coinsurance
Other Diagnostic
Examination at Free
Standing Location:
$10 copayment / visit
Other Diagnostic
Examination at Free
Standing Location:
30% coinsurance
X-Ray, Lab & Other
Examination at Outpatient
Hospital:
$35 copayment / visit
X-Ray, Lab & Other
Examination at Outpatient
Hospital:
30% coinsurance
Radiological & Nuclear
Imaging at Free Standing
Radiology Center:
10% coinsurance
Radiological & Nuclear
Imaging at Free Standing
Radiology Center:
30% coinsurance
Radiological & Nuclear
Imaging at Outpatient
Hospital:
10% coinsurance
Radiological & Nuclear
Imaging at Outpatient
Hospital:
30% coinsurance
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Limitations & Exceptions
Benefits in this section are for
diagnostic, non-preventive health
services.
X-Ray, Lab & Other Examination at
Outpatient Hospital:
The maximum allowed amount for
non-participating providers is $350
per day. Members are responsible for
30% of this $350 per day, plus all
charges in excess of $350.
Benefits in this section are for
diagnostic, non-preventive health
services.
Pre-authorization is required.
Radiological & Nuclear Imaging at
Outpatient Hospital:
The maximum allowed amount for
non-participating providers is $350
per day. Members are responsible for
30% of this $350 per day, plus all
charges in excess of $350.
Blue Shield of California is an independent
member of the Blue Shield Association.
4 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Your Cost If You Use a
Participating Provider
Retail:
$10 copayment /
prescription
Generic drugs
Mail Order:
$20 copayment /
prescription
Retail:
$25 copayment /
If you need drugs to
prescription
Brand Formulary Drugs
treat your illness or
Mail Order:
condition
$50 copayment /
prescription
More information
Retail:
about prescription
$40 copayment /
drug coverage is
prescription
available at
Brand Non-Formulary Drugs
Mail Order:
www.blueshieldca.com
$80 copayment /
prescription
If you have
outpatient surgery
Your Cost If You Use
a Non-Participating
Provider
Retail:
25% of billed amount
+ $10 copayment /
prescription
Mail Order:
Not Covered
Retail:
25% of billed amount
+ $25 copayment /
prescription
Mail Order:
Not Covered
Retail:
25% of billed amount
+ $40 copayment /
prescription
Mail Order:
Not Covered
Specialty drugs
30% coinsurance up to $200
copayment maximum /
Not Covered
prescription
Facility fee (e.g., ambulatory
surgery center)
10% coinsurance
30% coinsurance
Physician/surgeon fees
10% coinsurance
30% coinsurance
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Limitations & Exceptions
Retail: Covers up to a 30-day supply;
Mail Order: Covers up to a 90-day
supply.
Select formulary and non-formulary
drugs require pre-authorization.
Covers up to a 30-day supply.
Coverage limited to drugs dispensed
by select pharmacies in the Specialty
Pharmacy Network unless medically
necessary for a covered emergency.
Pre-authorization is required.
The maximum allowed amount for
non-participating providers is $350
per day. Members are responsible for
30% of this $350 per day, plus all
charges in excess of $350.
-------------------None-------------------
Blue Shield of California is an independent
member of the Blue Shield Association.
5 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Your Cost If You Use a
Participating Provider
Your Cost If You Use
a Non-Participating
Provider
Emergency room services
$100 copayment / visit
+ 10% coinsurance
$100 copayment / visit
+ 10% coinsurance
Copayment waived if admitted;
standard inpatient hospital facility
benefits apply.
Not subject to the calendar-year
medical deductible.
This is for the hospital/facility
charge only. The ER physician
charge is separate.
Coverage outside of California under
BlueCard.
Emergency medical
transportation
10% coinsurance
10% coinsurance
-------------------None-------------------
Urgent care
$10 copayment / visit at
freestanding urgent care
center
30% coinsurance at
freestanding urgent care
center
-------------------None-------------------
If you need
immediate medical
attention
If you have a
hospital stay
Limitations & Exceptions
Facility fee (e.g., hospital
room)
$100 copayment /
admission
+ 10% coinsurance
30% coinsurance
Physician/surgeon fee
10% coinsurance
30% coinsurance
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
The maximum allowed amount for
non-participating providers is $600
per day. Members are responsible for
30% of this $600 per day, plus all
charges in excess of $600.
Pre-authorization is required for all
services.
Failure to obtain pre-authorization
for special transplant services may
result in non-payment of benefits.
-------------------None-------------------
Blue Shield of California is an independent
member of the Blue Shield Association.
6 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Your Cost If You Use a
Participating Provider
Your Cost If You Use
a Non-Participating
Provider
Limitations & Exceptions
Mental Health Routine Outpatient
Services:
Services include
professional/physician office visits.
Not subject to the calendar-year
medical deductible at participating
providers.
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health
outpatient services
Mental Health Routine
Outpatient Services:
$10 copayment / visit
Mental Health Non-Routine
Outpatient Services:
10% coinsurance
Mental Health Routine
Outpatient Services:
30% coinsurance
Mental Health NonRoutine Outpatient
Services:
30% coinsurance
Mental Health Non-Routine
Outpatient Services:
Services include behavioral health
treatment, electroconvulsive therapy,
intensive outpatient programs, partial
hospitalization programs, and
transcranial magnetic stimulation.
Higher copayment and facility
charges per episode of care may
apply for partial hospitalization
programs.
Pre-authorization from Mental
Health Service Administrator
(MHSA) is required for non-routine
outpatient mental health services.
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
7 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Your Cost If You Use a
Participating Provider
Mental Health Inpatient
Hospital Services:
$100 copayment /
admission
+ 10% coinsurance
Mental/Behavioral health
inpatient services
Mental Health Residential
Services:
$100 copayment /
admission
+ 10% coinsurance
Mental Health Inpatient
Physician Services:
No Charge
Your Cost If You Use
a Non-Participating
Provider
Mental Health Inpatient
Hospital Services:
30% coinsurance
Mental Health Residential
Services:
30% coinsurance
Mental Health Inpatient
Physician Services:
30% coinsurance
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Limitations & Exceptions
The maximum allowed amount for
non-participating providers is $600
per day. Members are responsible for
30% of this $600 per day, plus all
charges in excess of $600.
Pre-authorization from Mental
Health Service Administrator
(MHSA) is required.
Blue Shield of California is an independent
member of the Blue Shield Association.
8 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Your Cost If You Use a
Participating Provider
Your Cost If You Use
a Non-Participating
Provider
Limitations & Exceptions
Substance Abuse Routine Outpatient
Services:
Services include
professional/physician office visits.
Not subject to the calendar-year
medical deductible at participating
providers.
Substance use disorder
outpatient services
Substance Abuse Routine
Outpatient Services:
$10 copayment / visit
Substance Abuse Routine
Outpatient Services:
30% coinsurance
Substance Abuse NonRoutine Outpatient
Services:
10% coinsurance
Substance Abuse NonRoutine Outpatient
Services:
30% coinsurance
Substance Abuse Non-Routine
Outpatient Services:
Services include partial
hospitalization program, intensive
outpatient program, and office-based
opioid treatment. Higher copayment
and facility charges per episode of
care may apply for partial
hospitalization programs.
Pre-authorization from Mental
Health Service Administrator
(MHSA) is required for non-routine
outpatient substance abuse services.
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
9 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Your Cost If You Use a
Participating Provider
Substance Abuse Inpatient
Hospital Services:
$100 copayment /
admission
+ 10% coinsurance
Substance use disorder
inpatient services
Prenatal and postnatal care
Substance Abuse Residential
Services:
$100 copayment /
admission
+ 10% coinsurance
Substance Abuse Inpatient
Physician Services:
No Charge
Prenatal:
10% coinsurance
Your Cost If You Use
a Non-Participating
Provider
Substance Abuse Inpatient
Hospital Services:
30% coinsurance
Substance Abuse
Residential Services:
30% coinsurance
Substance Abuse Inpatient
Physician Services:
30% coinsurance
Delivery and all inpatient
services
$100 copayment /
admission
+ 10% coinsurance
The maximum allowed amount for
non-participating providers is $600
per day. Members are responsible for
30% of this $600 per day, plus all
charges in excess of $600.
Pre-authorization from Mental
Health Service Administrator
(MHSA) is required.
30% coinsurance
Prenatal:
$10 copayment for initial visit only.
30% coinsurance
The maximum allowed amount for
non-participating providers is $600
per day. Members are responsible for
30% of this $600 per day, plus all
charges in excess of $600.
Postnatal:
10% coinsurance
If you are pregnant
Limitations & Exceptions
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
10 of 16
Pending Regulatory Approval
Common
Medical Event
Services You May Need
Home health care
If you need help
recovering or have
other special health
needs
Rehabilitation services
Habilitation services
Your Cost If You Use a
Participating Provider
Your Cost If You Use
a Non-Participating
Provider
10% coinsurance
Not Covered
Office visit:
$10 copayment / visit
Office visit:
50% coinsurance
Outpatient hospital:
$10 copayment / visit
Office visit:
$10 copayment / visit
Outpatient hospital:
30% coinsurance
Office visit:
50% coinsurance
Outpatient hospital:
$10 copayment / visit
Outpatient hospital:
30% coinsurance
Coverage limited to 100 visits per
member per calendar year. Nonparticipating home health care and
home infusion are not covered
unless pre-authorized. When these
services are pre-authorized, you pay
the participating provider
copayment.
Pre-authorization is required.
Coverage for physical, occupational
and respiratory therapy services.
Outpatient hospital:
The maximum allowed amount for
non-participating providers is $350
per day. Members are responsible for
30% of this $350 per day, plus all
charges in excess of $350.
Skilled nursing care
10% coinsurance at
freestanding skilled nursing
facility
10% coinsurance at
freestanding skilled nursing
facility
Durable medical equipment
10% coinsurance
30% coinsurance
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Limitations & Exceptions
Coverage limited to 100 days per
member per benefit period
combined with hospital/freestanding skilled nursing facility.
Pre-authorization is required.
Pre-authorization is required.
Blue Shield of California is an independent
member of the Blue Shield Association.
11 of 16
Pending Regulatory Approval
Common
Medical Event
If your child needs
dental or eye care
Services You May Need
Your Cost If You Use a
Participating Provider
Your Cost If You Use
a Non-Participating
Provider
Hospice service
No Charge
Not Covered
Eye exam
Glasses
Dental check-up
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Limitations & Exceptions
10% coinsurance applies for 24-hour
continuous home care and general
inpatient care hospice services.
All Hospice Program Benefits must
be pre-authorized by the Plan. (With
the exception of Pre-hospice
consultation.)
Failure to obtain pre-authorization
may result in non-payment of
benefits.
--------------------None-------------------------------------None-------------------------------------None------------------
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Cosmetic surgery

Dental care (Adult/Child)

Hearing aids

Infertility treatment

Long-term care

Non-emergency care when traveling outside
the U.S.

Private -duty nursing (unless enrolled in a
participating hospice program)

Routine eye care (Adult)

Routine foot care (unless for treatment of
diabetes)

Weight loss programs
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
12 of 16
Pending Regulatory Approval
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)

Acupuncture (coverage limited to 20
combined visits with chiropractic per calendar
year.)

Bariatric surgery (pre-authorization is
required. Failure to obtain pre-authorization
may result in non-payment of benefits.)

Chiropractic care (coverage limited to 12
visits per calendar year.)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-200-3242. You may also contact your state insurance department,
the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health
and Human Services at 1-877-267-2323 X 61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: 1-800-200-3242 or the Department of Labor’s Employee Benefits Security
Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your
appeal. Contact California Department of Managed Health Care Help at 1-888-466-2219 or visit http://www.healthhelp.ca.gov.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
13 of 16
Pending Regulatory Approval
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-346-7198.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-346-7198.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-866-346-7198.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-346-7198.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
14 of 16
Pending Regulatory Approval
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $6,240
 Patient pays $1,300
 Amount owed to providers: $5,400
 Plan pays $4,380
 Patient pays $1,020
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$250
$250
$650
$150
$1,300
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$250
$590
$100
$80
$1,020
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Blue Shield of California is an independent
member of the Blue Shield Association.
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Pending Regulatory Approval
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
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
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Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
Plan and patient payments are based on a
single person enrolled on the plan or
policy.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Yes. When you look at the Summary of
Does the Coverage Example
predict my own care needs?
 No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Questions: Call 1-800-200-3242 or visit us at www.blueshieldca.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-444-3272 to request a copy.
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Blue Shield of California is an independent
member of the Blue Shield Association.
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